When the Cure is Worse than the Illness
The opioid crisis is a real crisis. People are dying. Of course, the government looks for a clear bogeymen in these situations, since it makes for palatable political fodder. In the two decades after Ronald Regan took office as President, the main bogeymen for the drug crisis were the drug users themselves. The zero tolerance policy that the Federal Government and State legislatures adopted filled our prisons with drug users and small time drug dealers, creating hundreds of thousands of felons. It was good politics.
Drug users were easy targets, but ultimately, this was untenable. The cost to (white) families and the institutions that paid to house criminals was too great to bear. Now we see a reversal in attitude for these drug users. Somehow, governments began to recognize the immorality of housing our drug-addled neighbors. In many large metropolitan District Attorney’s offices, diversion programs are now accepted as the main way to handle drug arrests. The Federal Government has adjusted the sentencing guidelines downward.
So who is the bogeyman in the opioid crisis? The finger appears to be pointing to the medical Doctors who prescribe. The recent crack downs on Doctors, nurse practitioners and pharmacies across the nation who prescribe and dispense opioids show a clear policy by the Federal Government to stop the flow of opioids at the source. But are Doctors really the source, or is this just another example of the Government finding the easiest political target?
To be fair, there are dirty medical Doctors out there. The money is simply too great in the after market sale of opioids for some Doctors and nurse practitioners to resist. When an Oxycontin sells on the street for ten times its cost at CVS, someone is going to attempt to benefit from that margin. If a Doctor over prescribes an opioid simply to profit through kickbacks or under the table cash payments, she needs to be prosecuted fully. But what of the Doctor who prescribes opioids for pain in the ordinary course of his practice? Is he safe from prosecution? I don’t think so.
In a 2017 Fortune Magazine poll, interviewees were asked who was most at fault in the Opioid Epidemic. Drug users came out first, at 25%. Doctors came in second at 19%. The drug companies registered well below the answer “I don’t know”. With the recent busts of Doctors and Nurse practitioners, I venture to guess that if the question were asked today, Doctors would win in a landslide. This is troubling because it has the smell of political expediency.
I have represented many doctors. Currently I represent two. As a result of my interaction with these clients, I have had to become involved in their methodology in treating patients. I think most people don’t know that, long after medical school ends Doctors are continuously instructed on how they should handle patient complaints. Decades ago, it was not uncommon for Doctors to sparingly dispense pain medication because they were advised by the FDA, AMA and through their continuing education that pain medication was for temporary relief. That changed for them.
Around 1995 a movement developed in the medical community that chastised Doctors for not paying attention to and treating patients with chronic pain. The organizations that Doctors listened to, including the AMA, instructed Doctors to consider pain a “5th vital sign”, and to treat it accordingly. Not coincidently, this movement was joined and supported by the pharmaceutical companies that sold opioids. It became the common and accepted practice to prescribe medicines for pain, even chronic pain. This was considered good medicine.
My belief is that Doctors prescribing repeated doses of opioids will start being prosecuted, irrespective of their motivation for prescribing and whether or not a profit motive is involved. Some questionable pain clinics have been closed already, leaving their addicted patients on the street without their “fix”. The prosecution does not have the resources to treat those patients, even if they were inclined to do so. Where do these patients go?
It is an easy answer to state these patients should not be given pain medications at all. Some Doctors now refuse to prescribe pain meds for any patient, no matter how valid the complaint. However, patients seeking pain medication don’t come into the Doctor’s office and announce that they have recently been cut off from their pain pills because their clinic was closed. They have normal complaints. Back pain. Neck Pain. They describe in detail the symptoms for Fibromyalgia. A doctor can order an MRI and take blood tests, but ultimately they can”t be expected to assume a patient is lying. In fact, the vast majority isn’t lying, since their opioid addiction actually began with underlying and continuing pain. What is the compassionate response from a medical Doctor?
In fact, what should a Doctor do when he decides his patient has become dependent on his pain medication? Should he just cut her off? Most of the individuals who suggest this solution have absolutely no experience with the horrors of opioid withdrawal. There is a very good reason why an addicted person is willing to steal medications from a friend’s house or pay $80 for a Hydrocodone on the street. The pain of withdrawal, and the pain itself, requires it. Lets not forget that there are alternatives for the opioid addicted. Fentanyl and heroin are two of them.
If a patient refuses to detox and refuses treatment, what should be the best course of action for a Doctor? He could tell his patient he is on his own and cut him off. Some do. This virtually guarantees the Feds will not prosecute him, but leaves his patient on his own to take whatever means necessary to relieve his hideous withdrawal symptoms. If this patient buys his pills on the street, or turns to an illegal drug he will do so without any medical oversight.
Doctors may be in the cross hairs, but they are also caught in a Catch 22. Once told they were supposed to treat those who complained of pain, they are now told to ignore the pain of those who are addicted to opioids. And they are given no solution to this quagmire. Instead they are being vilified and probably facing prison time. The irony is the prosecution and public can ultimately defeat this opioid crisis by going after the Doctors, whether they over prescribed or not. Once the onslaught of prosecution begins, there won’t be a single legitimate Doctor that will dare prescribe an opioid for any purpose. Then the vacuum will be filled and we will have another crisis to deal with – that of opium based illegal drugs. The Doctors will be off the hook then, but none of us will be better off.